Financial Agreement

Our goal is to provide the highest quality of dental care possible and to have clear communication of our financial policy.

ALL ACCOUNTS ARE DUE AND PAYABLE AT TIME OF SERVICE. If a procedure requires multiple appointments, payment is required in full at the first appointment.

Payment options:

1. Cash

2. Check

3. MasterCard

4. Visa

5. Novus/Discover

6. Credit card authorization for recurring charges:

a. Treatment exceeds $200

b. Plan may not exceed 4 months

Patient with insurance: The PATIENT is responsible for the ESTIMATED non-covered portion, procedures and/or deductibles at the time of the service, OR the patient can sign a credit card authorization to bill their credit card AFTER insurance has paid for the visit. If the insurance company does not pay after 60 days, we will bill you directly for the full balance.

Parents not accompanying their child to an appointment must make PRIOR arrangements for payment (cash, check or credit card authorization).

Parents accompanying their children are financially responsible for payment.

18% annual interest is charged for any unpaid balance. A $15 fee is charged for nonpayment.

There is a $30.00 processing charge for non-sufficient funds or returned checks.

Records can be viewed at any time. There is a nominal charge for release or copies of records.

Because instruments, chairs, and personnel are reserved exclusively for your appointment, there is a $25 - $50 CHARGE FOR CHANGED OR BROKEN APPOINTMENTS LESS THAN 48 HOURS IN ADVANCE.

I,*

Full Name

agree to these financial terms.

Signature*

Date*

MonthDayYear

PATIENT

Patient Name*

First NameLast Name

Preferred Name to be called

Today's Date*

MonthDayYear

Gender*

MaleFemaleN/A

Date of Birth*

MonthDayYear

SS #

Home Phone

Area CodePhone Number

E-mail*

Marital Status

Cell Phone*

Area CodePhone Number

Mailing Address*

Street Address

CityState / Province

Postal / Zip Code

Home Address (if different)

Street Address

CityState / Province

Postal / Zip Code

Nearest Friend or Relative not living with you

Relationship

Phone

Area CodePhone Number

Address

Street Address

CityState / Province

Postal / Zip Code

Whom may we thank for referring you to our office?

Relationship

SELF IF MALE, HUSBAND, OR FATHER OF PATIENT IF APPLICABLE (PLEASE FILL OUT COMPLETELY) FINANCIAL RESPONSIBILITY

Person Responsible

First NameLast Name

Relationship

Home Phone

Area CodePhone Number

SS #

Driver's License #

Home Address

Street Address

CityState / Province

Postal / Zip Code

Employer

SelfNoneRet

Business Phone

Area CodePhone Number

Business Address

Street Address

CityState / Province

Postal / Zip Code

Occupation

SELF IF FEMALE, WIFE, OR MOTHER OF PATIENT IF APPLICABLE (PLEASE FILL OUT COMPLETELY) FINANCIAL RESPONSIBILITY

Person Responsible

First NameLast Name

Relationship

Home Phone

Area CodePhone Number

SS #

Driver's License #

Home Address

Street Address

CityState / Province

Postal / Zip Code

Employer

SelfNoneRet

Business Phone

Area CodePhone Number

Business Address

Street Address

CityState / Province

Postal / Zip Code

Occupation

IF PATIENT IS UNDER AGE 21

Full Time Student

YesNo

School Attending

City

Grade

Both Parents Name

Marital Status

If Parents are Divorced, Who has: Legal Custody?

MoFa

Financial Custody?

MoFa

PRIMARY DENTAL INSURANCE

NONEPA, MEDICAID, WELFARE (If None or PA, Turn Page Over)

Insurance Company Name

Insurance Company Address

Street Address

CityState / Province

Postal / Zip Code

Insurance Company Phone

Area CodePhone Number

Subscriber's Name

First NameLast Name

Subscriber's Date of Birth

MonthDayYear

Policy or Social Sec #

Group #

Group Name

Relationship of Patient to Subscriber

SelfSpouseChildOther

SECUNDARY DENTAL INSURANCE

NONE (If, Turn Page Over)

Insurance Company Name

Insurance Company Address

Street Address

CityState / Province

Postal / Zip Code

Insurance Company Phone

Area CodePhone Number

Subscriber's Name

First NameLast Name

Subscriber's Date of Birth

MonthDayYear

Policy or Social Sec #

Group #

Group Name

Relationship of Patient to Subscriber

SelfSpouseChildOther